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OBJECTIVE: Though initially protected from vessel dilation by estrogen, women may experience rapid abdominal aortic aneurysm (AAA) growth post-menopause. The rate of growth has been poorly defined in prior literature. Here, we describe aneurysm growth in a cohort of women found through an AAA screening program. METHODS: Women with AAAs were retrospectively identified. Aortic imaging was reviewed, and measurements of maximum transverse and anterior-posterior diameters were completed. Growth was stratified by the type of aortic pathology (fusiform aneurysm, aortic ectasia, dissection with aneurysmal degeneration, saccular aneurysm) as well as size category (<3 cm, 3.0-3.9 cm, 4.0-4.9 cm, ≥5.0 cm) at diagnosis. RESULTS: A cohort of 488 women was identified; 286 had multiple scans for review. The mean age of the entire cohort was 75 ± 9.9 years. Stratified by type of pathology, the mean age was 76 ± 8.9 years in patients with a fusiform AAA, 74 ± 9.8 years in ectasia, 65 ± 13.7 years in dissection, and 76 ± 5.6 years in saccular aneurysms. The maximum growth was highest in women with fusiform AAAs, followed by dissection, ectasia, and saccular pathology (9.7 mm, 7.0 mm, 3.0 mm, and 2.2 mm, respectively; P < .001). Comparing mean growth by year, the highest mean growth was in fusiform AAAs (3.6 mm vs 1.75 mm in dissection; P < .001). The Shapiro-Wilk test demonstrated that mean growth per year was non-normally distributed with a right skew. Stratified by aortic diameter at the time of diagnosis, mean growth/year increased with increasing size at diagnosis in fusiform AAAs and dissection (0.91 mm for <3 cm, 2.34 mm for 3.0-3.9 cm, 2.49 mm for 4.0-4.9 mm, and 6.16 mm for ≥5.0 cm in patients with fusiform AAAs vs 0.57 mm, 0.94 mm, 1.87 mm, and 2.66 mm, respectively, for patients with dissection). Smoking history was associated with a higher mean growth/year (2.6 mm vs 3.3 mm; P < .001). Conversely, patients with a family history of AAA had a lower mean growth/year (3.2 mm vs 1.5 mm; P < .001). CONCLUSIONS: The rate of aneurysm growth in women varies based on pathology and aneurysm size, and women experience rapid aneurysm growth at sizes greater than 4.5 cm. Current screening guidelines are inadequate, and our results demonstrate that the rate of growth of fusiform aneurysms in women is faster than in men at a smaller size and may warrant more frequent surveillance than current Society for Vascular Surgery recommendations to prevent risk of increased morbidity.
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Aneurisma de la Aorta Abdominal , Progresión de la Enfermedad , Humanos , Femenino , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/epidemiología , Estudios Retrospectivos , Anciano , Persona de Mediana Edad , Anciano de 80 o más Años , Factores de Riesgo , Factores de Tiempo , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/patología , Angiografía por Tomografía Computarizada , Aortografía , Factores Sexuales , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/epidemiología , Dilatación Patológica , PosmenopausiaRESUMEN
OBJECTIVE: Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication in carotid artery stenting. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease. METHODS: All consecutive patients who underwent TCAR+IVL from 2018-2022 at nine institutions were identified. IVL was combined with pre-dilatation angioplasty to treat calcified vessels before stent deployment. The primary outcome was a new ipsilateral stroke within 30 days. Secondary outcomes included any new ipsilateral neurologic event (stroke/transient ischemic attack [TIA]) at 30 days, technical success, and <30% residual stenosis. RESULTS: Fifty-eight patients (62% male; mean age, 78 ± 6.6 years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87 ± 27 minutes and 25 ± 14 minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29 mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having <30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30 days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P = .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P = .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132 days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period. CONCLUSIONS: IVL sufficiently remodels calcified carotid arteries to facilitate TCAR effectively in patients with traditionally prohibitive calcific disease. One patient (1.7%) suffered a stroke within 30 days, although four patients (6.8%) sustained any new neurological event (stroke/TIA). These results raise concerns about the risks of TCAR+IVL and whether it is an appropriate strategy for patients who could potentially undergo CEA.
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Estenosis Carotídea , Litotricia , Stents , Calcificación Vascular , Humanos , Masculino , Femenino , Anciano , Calcificación Vascular/terapia , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/complicaciones , Litotricia/efectos adversos , Estudios Retrospectivos , Resultado del Tratamiento , Factores de Riesgo , Anciano de 80 o más Años , Estenosis Carotídea/terapia , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Factores de Tiempo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/etiología , Medición de Riesgo , Estados Unidos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentaciónRESUMEN
OBJECTIVE: Radial artery access is a well-described technique that has proven to be safe and efficacious in percutaneous cardiac intervention. This technique has been used with increased frequency in the treatment of lower extremity peripheral arterial disease (LE-PAD); however, the overall safety has not yet been well described in the vascular surgery literature. We sought to evaluate the safety of this technique compared with retrograde femoral artery access and brachial artery access (BA) in the treatment of PAD. METHODS: The Vascular Quality Initiative database was used to identify all patients who underwent single site percutaneous access (retrograde femoral access [FA], BA, radial access [RA]) for treatment of LE-PAD from September 2016 through September 2019. Patients who underwent multiple access sites for intervention were excluded. Primary outcome was significant access site complications (ASCs), defined as those requiring treatment (blood transfusion, interventional treatment, or surgical treatment). Minor ASCs were also reported. RESULTS: The cohort comprised 61,203 patients (270 RA, 1210 BA, and 59,723 FA) with an average age of 68 years and who were 59.6% male. The RA and BA groups had higher rates of prior endarterectomy or bypass compared with the FA group (66.7% RA; 86.0% BA; 50.2% FA; P < .001). RA was more often used for single-segment treatments (82% vs 74% [P < .020] and more aortoiliac arterial segments (59.6% vs 21.0% [P < .001]). ASC occurred in 1329 patients (2.7%), including minor ASC (996 [1.6%]) and significant ASC (333 [0.54%]). Significant ASC were less common after FA and RA compared with BA (RA, 1 [0.37%]; FA, 307 [0.51%]; BA, 25 [2.1%]; P < .001). On multivariate analysis, BA was the strongest predictor of significant ASC (odds ratio, 2.75; 95% confidence interval, 1.73-4.36; P < .001). Significant ASC was no different after RA compared with FA (odds ratio, 0.60; 95% confidence interval, 0.08-4.33; P = .616). Other factors independently associated with significant ASC were sex, age, diabetes, chronic obstructive pulmonary disease, dialysis, and closure device use. CONCLUSIONS: RA as the primary access vessel for endovascular treatment of LE-PAD is safe when compared with other traditional access sites. When FA is not possible or desirable, the radial approach may provide suitable access to treatment with a better safety profile than BA.
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Arteria Braquial , Enfermedad Arterial Periférica , Humanos , Masculino , Anciano , Femenino , Arteria Braquial/cirugía , Arteria Femoral/cirugía , Factores de Riesgo , Resultado del Tratamiento , Arteria Radial , Extremidad Inferior , Estudios RetrospectivosRESUMEN
OBJECTIVE: Society for Vascular Surgery (SVS) recommendations for managing intimal (grade 1) blunt thoracic aortic injuries (BTAIs) include observation and medical management. University of Washington (UW) revised criteria suggest that intimal injuries with ≥1 cm flap should be upgraded to a moderate injury and treatment be considered. We sought to evaluate and compare SVS and UW criteria for BTAI and determine how discordance in grading affected treatment and outcome. METHODS: We reviewed all patients admitted with BTAI from January 1, 2011, to March 31, 2022. Data included injury grading, demographics, and concomitant traumatic injuries. Images were reviewed to categorize the injury with both grading systems. Treatment and outcomes were analyzed for concordant and discordant groups. RESULTS: Our cohort comprised 208 patients after excluding four who died upon arrival. The mean age was 45 ± 19 years, 69% were men, and the median injury severity score was 34 (interquartile range, 26-45). Strong agreement was observed between the grading systems (kappa = 0.88). All patients with concordant grade 1 injuries (n = 54) were observed. SVS grade 1/2 BTAIs were reclassified in 12 of 71 patients (16.9%). Two (28.6%) SVS grade 2 injuries were graded lower with the UW criteria; neither patient required immediate or delayed repair. Ten (15.6%) SVS grade 1 BTAIs were graded higher with UW criteria. Of these, six underwent repair (one for preoperative embolization), and four were observed without sequalae. Overall mortality was 7.7% with no difference for concordant or discordant grades (7.7% vs 8.3%; P = .99). No aneurysm-related mortalities were observed. Follow-up imaging was available for 94 survivors (49.0%) at a median of 193 days (interquartile range, 42-522 days). Two patients unrepaired at the index hospitalization (SVS grade 3/UW grade 2) underwent successful delayed repair. No patient observed for a minimal injury had BTAI progression or required treatment. CONCLUSIONS: The UW grading system may upgrade or downgrade SVS grade 1 or 2 BTAI for as many as one in six injuries. Upgraded injuries should prompt consideration of repair if there is evidence of flap progression or thromboembolic complications. Downgraded injuries suggest that treatment may not be necessary; clinical expertise is key to determine optimal management in these patients.
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Procedimientos Endovasculares , Traumatismos Torácicos , Lesiones del Sistema Vascular , Heridas no Penetrantes , Masculino , Humanos , Adulto , Persona de Mediana Edad , Femenino , Procedimientos Endovasculares/efectos adversos , Resultado del Tratamiento , Factores de Riesgo , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugía , Factores de Tiempo , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/cirugía , Traumatismos Torácicos/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aorta Torácica/lesiones , Estudios RetrospectivosRESUMEN
BACKGROUND: Objective measures of perfusion such as an ankle-brachial index (ABI) and toe pressure remain important in prognosticating wound healing. However, the use of ABI is limited in patients with incompressible vessels and toe pressure may not be comparable across patients. While a toe arm index (TAI) may be of value in this setting, its role as clinical indicator of perfusion for healing in patients with lower-extremity wounds has not been well established. METHODS: A retrospective review was performed of all vascular patients with lower-extremity wounds that underwent peripheral vascular intervention between 2014-2019. Data regarding patient demographics, comorbidities, TAI, ABI, toe pressures, and the wound, ischemia, and foot infection (WIfI) score were collected. Associations between patient variables and wound healing at various time points were evaluated. RESULTS: A total of 173 patients (67.7 ± 10.9 years; 71.1% male) were identified with lower-extremity wounds. Most patients underwent endovascular intervention (77.5%). Patients were followed for a median of 416 (IQR 129-900) days. Mean postoperative TAI was 0.35 ± 0.19 and mean WIfI score was 2.60 ± 1.17. Nine percent (15) of patients healed within 1 month, 44.8% (69) healed within 6 months, and 65.5% (97) healed within 1 year of revascularization without need for major amputation. Those that healed within 1 year without any major amputation did not differ from those that did not heal based on age, gender, race, comorbidities, periprocedural medications, or procedures performed. However, patients that healed without major amputation had a higher postoperative TAI (0.38 vs. 0.30, P = 0.02), higher toe pressure (53 vs. 40 mm Hg, P = 0.004), and lower WIfI score (2.26 vs. 3.12, P < 0.001). Patients that healed with 1 year without requiring any amputation had similar associations with postoperative TAI, toe pressure, and WIfI. Additionally, they were more likely to be White (P = 0.019) and have an open surgical procedure (P < 0.001) and less likely to have chronic kidney disease (P = 0.001) or diabetes (P = 0.008). A Youden index was calculated and identified a TAI value of 0.30 that optimized sensitivity and specificity for wound healing. The area under the curve for TAI as a predictor of wound healing was 0.62. CONCLUSIONS: Higher postoperative TAI is associated with higher odds of wound healing without need for major amputation. Toe arm index is therefore a useful tool to identify patients with adequate arterial perfusion to heal lower-extremity wounds. However, the area under the curve is poor for TAI when used as a sole predictor of wound healing potential suggesting that TAI should be one of multiple factors to considered when prognosticating wound healing potential.
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Índice Tobillo Braquial , Enfermedad Arterial Periférica , Femenino , Humanos , Masculino , Brazo , Isquemia/diagnóstico , Isquemia/cirugía , Recuperación del Miembro , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/terapia , Estudios Retrospectivos , Factores de Riesgo , Dedos del Pie/cirugía , Resultado del Tratamiento , Cicatrización de Heridas , Persona de Mediana Edad , AncianoRESUMEN
BACKGROUND: The safety and efficacy of right axillary cannulation during complex aortic aneurysm repair for the deployment of chimney grafts is controversial; however, there are few studies that compare right and left upper extremity access. We favor the right axillary approach because of the relative ease of access to the visceral branches and the ability of surgeons and nursing staff to work on the same side of the patient, while avoiding the left sided image intensifier. We aim to demonstrate that right-sided access is equivalent or safer than left-sided access in terms of technical success and complication rates, with a focus on neurologic outcomes. METHODS: This is a single-institution retrospective study with a review of patients who underwent aortic intervention from January 2012 through December 2018. A total of 398 aortic interventions were performed, and 97 of these required brachial, axillary, or subclavian arterial access for attempted ChEVAR or thoracic endovascular aortic repair with parallel chimney grafts. Primary end points that were analyzed were site or sites of upper extremity access, technical success, 30-day mortality, cerebrovascular events, and subclavian/axillary artery injury. The number of parallel grafts, age, mean hospital length of stay, prior aortic intervention, emergent or elective status were also analyzed. RESULTS: Ninety-seven endovascular aortic operations required upper extremity access, with 67 using access from the right upper extremity, 26 using access from the left upper extremity, and 4 using bilateral upper extremity access. A total of 68.0% of patients had undergone prior aortic surgery. Technical success was achieved in 85 cases (87.6%). Five total patients suffered cerebrovascular accidents, with 2 occurring in left-sided access (7.7%), 2 in right-sided access (3.0%), and 1 in bilateral access (25%). CONCLUSIONS: Right upper extremity access for patients undergoing parallel graft placement during endovascular aortic aneurysm repair is a safe and feasible approach that is not associated with an increased risk of stroke or neurological events as compared with left upper extremity access.
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Aneurisma de la Aorta/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Cateterismo Periférico , Procedimientos Endovasculares , Extremidad Superior/irrigación sanguínea , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: We sought to determine whether flow velocities measured using Doppler ultrasonography after endovascular aortic aneurysm repair (EVAR) can predict for resolution of type II endoleaks without intervention. We also assessed the relationship of the flow velocities to sac growth and the need for intervention. We hypothesized that hemodynamic properties suggesting low flow velocity would predict for resolution of type II endoleaks. METHODS: The data from 23 patients with type II endoleaks identified on Doppler ultrasonography after EVAR from January 2014 to December 2017 were retrospectively analyzed. The 23 patients with type II endoleaks were split into two groups. Group 1 included the 13 patients with resolved endoleaks or shrinking sac size and group 2, the 10 patients with an increasing sac size or those requiring intervention to seal the endoleak because of an increased sac size. We analyzed the velocities of the endoleak nidus. RESULTS: Doppler ultrasound velocities were significantly lower in patients with resolved type II endoleaks and those with a shrinking aneurysm sac size compared with those demonstrating an increase in aneurysm sac size (42.6 ± 25.2 cm/s vs 219.5 ± 84.1 cm/s; P < .0001). Of the 10 patients in group 2, nine had required intervention with either translumbar embolization or transarterial embolization, with only two experiencing complete resolution of the type II endoleak, despite the intervention. All patients in group 2 had had ≥1 duplex ultrasound scan with endoleak nidus velocities >100 cm/s. In contrast, no patient in group 1 had had any duplex ultrasound scan with endoleak nidus velocities >100 cm/s. CONCLUSIONS: The Doppler ultrasound velocities of type II endoleaks might be able to predict for spontaneous resolution of type II endoleaks or increased sac growth. Type II endoleaks on Doppler ultrasonography with endoleak nidus velocities >100 cm/s can persistent, even with attempted treatment.
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Endofuga/diagnóstico por imagen , Ultrasonografía Doppler Dúplex , Anciano de 80 o más Años , Aneurisma de la Aorta/cirugía , Velocidad del Flujo Sanguíneo , Procedimientos Endovasculares , Femenino , Humanos , Masculino , Estudios RetrospectivosRESUMEN
BACKGROUND: Vascular injuries may be challenging, particularly for surgeons who have not received formal vascular surgery fellowship training. Lack of experience and improper technique can result in significant complications. The objective of this study was to examine changes in resident experience with operative vascular trauma over time. METHODS: A retrospective review was performed using Accreditation Council for Graduate Medical Education (ACGME) case logs of general surgery residents graduating between 2004 and 2014 at 2 academic, university-affiliated institutions associated with level 1 trauma centers. The primary outcome was number of reported vascular trauma operations, stratified by year of graduation and institution. RESULTS: A total of 112 residents graduated in the study period with a median 7 (interquartile range 4.5-13.5) vascular trauma cases per resident. Fasciotomy and exposure and/or repair of peripheral vessels constituted the bulk of the operative volume. Linear regression showed no significant trend in cases with respect to year of graduation (P = 0.266). Residents from program A (n = 53) reported a significantly higher number of vascular trauma cases when compared with program B (n = 59): 12.0 vs. 5.0 cases, respectively (P < 0.001). CONCLUSIONS: Level 1 trauma center verification does not guarantee sufficient exposure to vascular trauma. The operative exposure in program B is reflective of the national average of 4.0 cases per resident as reported by the ACGME, and this trend is unlikely to change in the near future. Fellowship training may be critical for surgeons who plan to work in a trauma setting, particularly in areas lacking vascular surgeons.
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Educación de Postgrado en Medicina , Cirugía General/educación , Internado y Residencia , Procedimientos Quirúrgicos Vasculares/educación , Lesiones del Sistema Vascular/cirugía , Carga de Trabajo , Centros Médicos Académicos , California , Competencia Clínica , Curriculum , Fasciotomía/educación , Humanos , Curva de Aprendizaje , Modelos Lineales , Evaluación de Programas y Proyectos de Salud , Registros , Estudios Retrospectivos , Lesiones del Sistema Vascular/diagnósticoRESUMEN
The Gore TAG thoracic branch endoprosthesis (TBE) is the first Food and Drug Administration-approved device for zone 2 thoracic endovascular aortic repair, allowing for graft placement proximal to the left subclavian artery origin and maintaining vessel patency through a side branch. We describe our experience with the Gore TBE device in 20 patients for acute indications, including blunt thoracic aortic injuries, complicated dissections, and ruptured aneurysms. Technical success, with exclusion of pathology and left subclavian patency, was 100% without major complications within 30 days. Our early Gore TBE device experience demonstrates safe use in acute aortic pathology without an increased risk of complications.
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Transcarotid artery revascularization (TCAR) provides a safe alternative to carotid endarterectomy. The anatomic requirements include a 5-cm minimum clavicle to carotid bifurcation distance for sheath access proximal to the lesion. In the present report, we describe our experience with conduit use for patients not meeting that requirement. Patients undergoing elective TCAR with a conduit from 2021 to 2022 were retrospectively identified. After carotid artery exposure, a 6-mm prosthetic graft was anastomosed to the common carotid artery in an end-to-side fashion. After stent delivery, the conduit was ligated and oversewn. The patient demographics, procedural details, and outcomes were recorded and compared with our nonconduit TCAR experience. A total of 11 patients (64% male; age, 75 ± 5 years) underwent TCAR with a conduit, 5 (46%) for symptomatic disease, and 77 patients underwent TCAR with no conduit, 52 (60%) with symptomatic disease (P = .50). Other than a higher rate of prior coronary interventions in the conduit group (55% vs 47%; P = .007), no significant differences were found in age, gender, race, comorbidities, or high risk for carotid endarterectomy criteria. In the conduit group, the average skin to carotid artery depth was 4.2 cm (range, 1.9-6.1 cm). The average clavicle to bifurcation distance was 4.4 cm (range, 3.3-4.9 cm) vs 6.5 cm (range, 3.3-9.7 cm; P = .002) in the nonconduit group. Dacron was the most common conduit material used (73%). No differences were found in the mean procedure times (121 ± 32 vs 129 ± 53 minutes; P = .785) or flow reversal times (14 ± 5 vs 19 ± 13 minutes; P =.989) for the conduit and nonconduit cohorts, respectively. Technical success was achieved in 100% of the conduit and nonconduit cases. Excluding one outlier of a prolonged stay (7 days) for management of unrelated medical issues (gastrostomy tube placement for chronic dysphagia after mass resection and neck radiation), the mean hospital stay was 2 days (1.2 ± 0.4 intensive care unit days) compared with 3.8 ± 5.7 days for our nonconduit cohort (P = .2). Hypotension was the most common reason for delayed discharge for the conduit group (n = 3; 27%). The average follow-up was 2.7 months (range, 1-10 months). For all 11 conduit patients, the stent remained patent without stenosis, thrombus, or pseudoaneurysm at the conduit stump site on surveillance duplex ultrasound. No strokes or complications had occurred at 30 days in the conduit group compared with four strokes or transient ischemic attacks (P = .469) and 18 minor complications in the nonconduit group (P = .091). For patients lacking a sufficient distance between the clavicle and carotid artery bifurcation, a prosthetic conduit facilitates safe use of flow reversal for stent delivery and can be ligated at procedural completion without consequences.
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The focused assessment with sonography for trauma (FAST) examination has become the standard of care for rapid evaluation of trauma patients. Extended FAST (eFAST) is the use of ultrasonography for the detection of pneumothorax (PTX). The exact sensitivity and specificity of eFAST detecting traumatic PTX during practical "real-life" application is yet to be investigated. This is a retrospective review of all trauma patients with a diagnosis of PTX, who were treated at a large level 1 urban trauma center from March 2013 through July 2014. Charts were reviewed for results of imaging, which included eFAST, chest X-ray, and CT scan. The requirement of tube thoracostomy and mechanism of injury were also analyzed. A total of 369 patients with a diagnosis of PTX were identified. A total of 69 patients were excluded, as eFAST was either not performed or not documented, leaving 300 patients identified with PTX. A total of 113 patients had clinically significant PTX (37.6%), requiring immediate tube thoracostomy placement. eFAST yielded a positive diagnosis of PTX in 19 patients (16.8%), and all were clinically significant, requiring tube thoracostomy. Chest X-ray detected clinically significant PTX in 105 patients (92.9%). The literature on the utility of eFAST for PTX in trauma is variable. Our data show that although specific for clinically significant traumatic PTX, it has poor sensitivity when performed by clinicians with variable levels of ultrasound training. We conclude that CT is still the gold standard in detecting PTX, and clinicians performing eFAST should have adequate training.
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Hospitales Urbanos , Neumotórax/diagnóstico por imagen , Centros Traumatológicos , Humanos , Neumotórax/cirugía , Estudios Retrospectivos , Sensibilidad y Especificidad , Toracostomía , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
OBJECTIVE: Transcatheter aortic valve replacement (TAVR) procedures were introduced in 2011. Initially, procedures were limited to patients who were not surgical candidates, but subsequently high-risk surgical candidates were considered for TAVR. The influence on aortic valve surgery in California is unknown. METHODS: The California Office of Statewide Health Planning and Development hospitalized patient discharge database was queried for the years 2009 through 2014. isolated surgical aortic valve and aortic valve/coronary artery bypass graft (SAVR) and TAVR procedures were identified by International Classification of Diseases-9th revision clinical modification procedure codes. Seven TAVR programs were introduced in 2011, 12 in 2012, 3 in 2013, and 6 in 2014. SAVR procedure volumes were compared from the 2 years before institution with SAVR volumes during the year(s) after institution of the TAVR program in these 28 hospitals. RESULTS: Overall, surgical volumes increased during the first, second, and third years after implementation of TAVR procedures. Among 7 hospitals with 4-year programs, surgical volumes increased to a maximum of 15.5% during the third year, then began to decrease. The hospital performing the largest number of TAVR procedures showed a marked decrease in SAVR volume by the fourth year, suggesting a shift of SAVR candidates to TAVR. Among all hospitals with 4-year programs, TAVR exceeded SAVR procedures by the fourth year. In California overall, SAVR increased during 2011 through 2013, due primarily to increasing volume of isolated SAVR procedures. Statewide, isolated SAVR increased from a yearly average of 3111 procedures during 2009-2010 to 3592 (+15.5%) in 2013, then decreased slightly in 2014. SAVR plus coronary artery bypass graft procedures decreased during the same time period. CONCLUSIONS: After implementation of TAVR, hospital SAVR volumes increased moderately, then began to decrease by the fourth year, when TAVR volume exceeded SAVR. Surgical candidates may be identified during evaluation for TAVR, resulting in increased SAVR volume. Increasing SAVR volume may also be related to improved patient and provider awareness of aortic valve disease.
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Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/tendencias , Reemplazo de la Válvula Aórtica Transcatéter/tendencias , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , California/epidemiología , Comorbilidad , Puente de Arteria Coronaria/tendencias , Bases de Datos Factuales , Femenino , Enfermedades de las Válvulas Cardíacas/epidemiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Hospitales de Alto Volumen/tendencias , Hospitales de Bajo Volumen/tendencias , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del Tratamiento , Adulto JovenRESUMEN
With the incidence of burns decreasing nationally, burn units are caring for more patients with nonburn conditions. The American Burn Association National Burn Repository does not currently report data regarding patients cared for in burn units without a diagnosis of burn. Using the National Inpatient Sample, we examined if there was a difference in characteristics and outcomes of patients admitted for burns compared with those with a primary admitting diagnosis of necrotizing skin infections and soft-tissue infections and exfoliative skin conditions. This is a retrospective study querying the National Inpatient Sample database to identify 56,102 patients from 2007 to 2012 who were admitted with a diagnosis of a burn (burn group). This group was then compared with 375,857 patients who had a primary admitting diagnosis of a necrotizing skin and/or soft-tissue infection or exfoliative skin conditions (nonburn group). Clinical and demographic variables were analyzed to determine characteristics of each patient group including length of stay, disposition, complications, comorbidities, and mortality. The average age of the nonburn group was 63.7 years, whereas the average age of the burn group was 40.1 years. Overall length of stay was higher in the nonburn patients than in burn patients (10.5 vs 8.4 days, P < .001). Nonburn patients had a higher rate of medical comorbidities. Nonburn patients had higher rates of mortality (6.9% vs 2.7%) and complications. After adjusting for confounders, such as age, gender, ethnicity, and comorbidities, the nonburn group was found to have higher rates of all recorded complications. Burn patients were more likely to undergo a major operating room procedure (39.3% vs 28.1%) and routine discharge (68.4% vs 26.3%) compared with the nonburn group. Patients with necrotizing skin and soft-tissue infections and exfoliative skin conditions are older, have more comorbidities, higher complication rates, and higher mortality rates than burn patients. Given these findings, burn units may need to adjust their resource utilization, competencies, and research priorities to improve the quality of care being delivered to these two different populations.
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Unidades de Quemados/estadística & datos numéricos , Quemaduras/epidemiología , Quemaduras/terapia , Enfermedades de la Piel/epidemiología , Enfermedades de la Piel/terapia , Infecciones de los Tejidos Blandos/epidemiología , Infecciones de los Tejidos Blandos/terapia , Adulto , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: It has been well documented that the use of alcohol correlates with injury risk, especially in DUI (driving under the influence) and DWI (driving while intoxicated). Consumption of alcohol in patients presenting with bicycle-related injuries is associated with greater injury severity, longer hospitalization, and higher health care costs. We hypothesized that intoxicated patients operating a bicycle with traumatic injuries have previous DUI or DWI convictions and had lost their privilege to drive a motor vehicle, resorted to bicycling, and had continued alcohol consumption despite negative previous consequences. METHODS: We retrospectively collected data on injured bicyclists older than 18 years with positive blood alcohol content levels treated from the period January 2009 to June 2014 at a large Level 1 urban trauma center. We then matched each patient by name and date of birth and were able to obtain public criminal records through the Superior Court of California for the local of county. RESULTS: A total of 149 injured bicyclists with positive blood alcohol levels were identified. Their average blood alcohol content was 236.0 mg/dL, and their average age was 41 years. Sixty-six (44.2%) of these patients had prior DUI/DWI convictions with suspension of driving privileges. Ninety-five patients in this group (63.8%) had no health insurance, and 51 patients (34.2%) tested positive for other drugs. Intoxicated bicyclists trended toward longer hospital length compared with nonintoxicated bicyclists (4.60 vs. 3.44 days; p = 0.07). Three (0.02%) of 149 patients were charged with bicycling while intoxicated. CONCLUSION: Intoxicated bicyclists involved in trauma are more likely to have a previous DUI/DWI, have other drug use, tend to have longer hospital stays, and are less likely to have insurance. Bicycle safety education and behavior modification targeting DUI/DWI offenders are warranted. In order to promote injury prevention, resources to increase awareness of this underestimated public health issue should be promoted. LEVEL OF EVIDENCE: Epidemiologic study, level III.
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Conducción de Automóvil/legislación & jurisprudencia , Ciclismo/lesiones , Trastornos Relacionados con Sustancias/complicaciones , Adulto , California/epidemiología , Femenino , Dispositivos de Protección de la Cabeza/estadística & datos numéricos , Humanos , Puntaje de Gravedad del Traumatismo , Seguro de Salud/estadística & datos numéricos , Masculino , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Trastornos Relacionados con Sustancias/epidemiología , Centros TraumatológicosRESUMEN
OBJECTIVE: Death is an important outcome of procedural interventions. The death rate, or mortality rate, is subject to variability by definition. The Society of Thoracic Surgeons Adult Cardiac Surgery Database definition of "operative" mortality originally included all in-hospital deaths and deaths occurring within 30 days of the procedure. In recent versions of the Society of Thoracic Surgeons Adult Cardiac Surgery Database, "in-hospital" has been modified to include "patients transferred to other acute care facilities," and "deaths within 30 days unless clearly unrelated to the procedure" has been changed to "deaths within 30 days regardless of cause." This study addresses the impact of these redefinitions on outcome reporting. METHODS: The California Office of Statewide Health Planning and Development hospitalized patient discharge database was queried for the year 2009, the most recent year that data files could be linked to the vital statistics death files to include all-cause mortality. Isolated coronary artery bypass grafting, isolated valve, coronary artery bypass grafting valve, and percutaneous coronary intervention procedures were identified by International Classification of Diseases, Ninth Edition, Clinical Modification procedure codes. Percutaneous coronary intervention procedures were further divided into acute coronary syndrome (percutaneous coronary intervention acute coronary syndrome) and all other percutaneous coronary intervention (percutaneous coronary intervention no acute coronary syndrome). Deaths were counted by 5 methods depending on the time and place of occurrence: (1) in-hospital or during the index hospitalization; (2) in-hospital + connected hospitalization, defined as a transfer to another acute care facility on the same day or within 24 hours of discharge; (3) in-hospital + 30 day, death during index hospitalization or within 30 days after the procedure; (4) in-hospital + connected + 30 day readmission, death during index hospitalization, transfer to acute care facility, or deaths during readmission within 30 days; and (5) in-hospital + connected + 30 day. To study the impact of these operative mortality definitions, we examined 5 different methods to track mortality and performed 2 separate analyses. The first analysis did not exclude any patients, and the second analysis excluded any patient who could not be accurately tracked after hospital discharge. RESULTS: In the first analysis with no patients excluded, a total of 17% (117/697) of surgical deaths and 31% (409/1324) of percutaneous coronary intervention deaths were counted after the original hospitalization. The highest percentage of posthospital deaths occurred after elective percutaneous coronary intervention: 45% (135/301). In surgical patients, the highest percentage of posthospital deaths occurred in coronary artery bypass grafting procedures: 20% (57/284). In the second analysis, with untrackable patients excluded, hospital deaths included 12% (161/1324) for percutaneous coronary intervention compared with 4% (30/697) for surgical procedures. CONCLUSIONS: A significant percentage of procedural deaths occur after transfer or discharge from the index hospital. This is especially evident in the percutaneous coronary intervention group. These findings illustrate the importance of the definition of "operative" mortality and the need to ensure accuracy in the reporting of data to voluntary clinical registries, such as the Society of Thoracic Surgeons Adult Cardiac Surgery Database and National Cardiovascular Data Registry.
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Procedimientos Quirúrgicos Cardíacos/mortalidad , Cardiopatías/cirugía , Intervención Coronaria Percutánea/mortalidad , Proyectos de Investigación/estadística & datos numéricos , Terminología como Asunto , California/epidemiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/tendencias , Puente de Arteria Coronaria/mortalidad , Bases de Datos Factuales/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/mortalidad , Cardiopatías/diagnóstico , Cardiopatías/mortalidad , Mortalidad Hospitalaria/tendencias , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/tendencias , Indicadores de Calidad de la Atención de Salud , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
The necessity of routine endoscopic retrograde cholangiopancreatography (ERCP) after positive intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy is not well defined. We aimed to examine the incidence of positive IOC among patients who undergo IOC during cholecystectomy and the rate of subsequent ERCP stone extraction. The Nationwide Inpatient Sample database was reviewed for all patients undergoing cholecystectomy with IOC from 2002 to 2012. Patients were then analyzed for ERCP and stone extraction. A total of 73,508 patients who underwent cholecystectomy with IOC for a diagnosis of acute cholecystitis and found to have a bile duct stone were identified. Of these patients, 5915 underwent subsequent ERCP. In the patients that underwent subsequent ERCP, 1478 had a documented stone extraction during ERCP. The rate of stone extraction in the ERCP subset is 25 per cent, which is 2 per cent of all patients who had a positive IOC. The rate of stone extraction after positive IOC is low. Positive IOC may not warrant a routine postoperative ERCP. Our results suggest that clinical monitoring of patients with positive IOC is reasonable, as the majority of patients with a positive IOC ultimately have no stone extraction.
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Colangiografía/métodos , Colangiopancreatografia Retrógrada Endoscópica/estadística & datos numéricos , Colecistectomía/métodos , Colecistitis Aguda/diagnóstico , Procedimientos Innecesarios , Anciano , Colecistectomía/estadística & datos numéricos , Colecistectomía Laparoscópica/métodos , Colecistectomía Laparoscópica/estadística & datos numéricos , Colecistitis Aguda/cirugía , Bases de Datos Factuales , Femenino , Humanos , Cuidados Intraoperatorios/métodos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Disparities in access to health care between white and minority patients are well described. We aimed to analyze the trends and outcomes of cholecystectomy based on racial classification. The Nationwide Inpatient Sample database was reviewed for all patients undergoing cholecystectomy from 2009 to 2012. Patients were stratified as white or non-white. A total of 243,536 patients were analyzed: 159,901 white and 83,635 non-white. Non-white patients had significantly higher proportions of Medicaid (25% vs 9.3%), self-pay (14% vs 7.1%), and no-charge (1.8% vs 0.64%). Non-white patients had significantly higher rates of emergent admission (84% vs 78%) compared with the white patients. Multivariate analysis revealed that non-whites had a significantly longer length of stay [mean difference of 0.14 days, 95% confidence interval (CI) 0.08-0.20] and higher total hospital charges (mean difference of $6748.00, 95% CI 5994.19-7501.81) than whites, despite a lower morbidity (odds ratio 0.94, 95% CI 0.90-0.98). Use of laparoscopy and mortality were not different. These differences persisted on subgroup analysis by insurance type. These findings suggest a gap in access to and outcomes of cholecystectomy in the minority population nationwide.
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Colecistectomía/economía , Medicaid/economía , Evaluación de Resultado en la Atención de Salud , Racismo/estadística & datos numéricos , Adulto , Anciano , Población Negra/estadística & datos numéricos , Colecistectomía/métodos , Colecistectomía/estadística & datos numéricos , Bases de Datos Factuales , Femenino , Costos de la Atención en Salud , Disparidades en Atención de Salud/estadística & datos numéricos , Humanos , Cobertura del Seguro/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Evaluación de Necesidades , Estudios Retrospectivos , Medición de Riesgo , Estados Unidos , Población Blanca/estadística & datos numéricosRESUMEN
Advances in endovascular surgery have resulted in a decline in major open arterial reconstructions nationwide. Our objective is to investigate the effect of endovascular surgery on general surgery resident experience with open vascular surgery. Between 2004 and 2014, 112 residents graduated from two academic institutions in Southern California. Residents were separated into those who graduated in 2004 to 2008 (period 1) and in 2009 to 2014 (period 2). Case volumes of vascular procedures were compared using two-sample t test. A total of 43 residents were in period 1 and 59 residents were in period 2. In aggregate, there was no significant difference in open cases recorded between the two periods (84 vs 87, P = 0.194). Subgroup analysis showed period 2 recorded significantly fewer cases of open aneurysm repair (5 vs 3, P < 0.001), cerebrovascular (14 vs 10, P = 0.007), and peripheral obstructive procedures (16 vs 13, P = 0.017). Dialysis access procedures constituted the largest group of procedures and remained similar between the two periods (35 vs 42, P = 0.582). General surgery residents experienced a significant decline in several index open major arterial reconstruction cases. This decline was offset by maintenance of dialysis access procedures. If the trend continues, future general surgeons will not be proficient in open vascular procedures.